United Nations Directories for Electronic Data Interchange for
Administration, Commerce and Transport

UN/EDIFACT

Message Type : IHCLME
Version : D
Release : 12A
Contr. Agency: UN
Revision : 1
Date : 2012-08-17
SOURCE: TBG10 Healthcare
CONTENTS
Health care claim or encounter request and response - interactive message
0. INTRODUCTION
1. SCOPE
1.1 Functional definition
1.2 Field of application
1.3 Principles
2. REFERENCES
3. TERMS AND DEFINITIONS
3.1 Standard terms and definitions
4. MESSAGE DEFINITION
4.1 Segment clarification
4.2 Segment index (alphabetical sequence by tag)
4.3 Message structure
4.3.1 Segment table
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For general information on UN standard message types see UN Trade Data
Interchange Directory, UNTDID, Part 4, Section 2.3, UN/ECE UNSM
General Introduction
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0. INTRODUCTION
This specification provides the definition of the Health care claim
or encounter request and response - interactive message (IHCLME) to
be used in Electronic Data Interchange (EDI) between trading
partners involved in administration, commerce and transport.
1. SCOPE
1.1 Functional definition
This message is to support interactive submittal and response of
health care claims or encounters for the point of sale environment.
It will be used in health care information scenarios when immediate
response is appropriate.
1.2 Field of application
The Health care claim or encounter request and response -
interactive message may be used for both national and international
applications. It is based on universal practice related to
administration, commerce and transport, and is not dependent on the
type of business or industry.
1.3 Principles
This message establishes the data contents of the IHCLME.
This can be used to create interactive communications between health
care providers (e.g., physicians, hospitals, other medical
facilities, dentists, etc.), health care information processors,
health care payers, and/or their agents. The information includes,
but is not limited to, billing information (for full or partial
adjudication), encounter reporting, additional service information
(denial reasons, errors, pending data, etc.), and coordination of
benefits.
IHCLME may be used for the following functions within the claim or
encounter scenario for health care:
(1) To request and respond to a request for processing a claim or
encounter episode.
(2) To request and respond to a request to modify or cancel a
previously submitted claim or encounter.
(3) To request and respond to a pre-determination of benefits as it
relates to a covered life.
(4) To request and respond to a need for additional information as
it relates to a claim or encounter episode.
An example of health care processors or their agents includes:
- Insurance Companies
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- Health Care Purchasers (e.g., employers)
- Professional Review Organizations (PROs)
- Social Worker Organizations
- Health Care Providers (e.g., physicians, hospitals, laboratories)
- Third Party Administrators (TPAs)
- Health Care Vendors (e.g., practice management vendors, billing
services)
- Service Bureaus (value added networks or value added banks)
- Government agencies such as Medicare, Medicaid and Civilian
Health and Medical Program of the Uniformed Services
(CHAMPUS).
2. REFERENCES
See UNTDID, Part 4, Chapter 2.3 UN/ECE UNSM - General Introduction,
Section 1.
3. TERMS AND DEFINITIONS
3.1 Standard terms and definitions
See UNTDID, Part 4, Chapter 2.3 UN/ECE UNSM - General Introduction,
Section 2.
4. MESSAGE DEFINITION
4.1 Segment clarification
This section should be read in conjunction with the segment table
which indicates mandatory, conditional and repeating requirements.
00010UIH, Interactive message header
A service segment starting and uniquely identifying a message. The
message type code for the Health care claim or encounter request
and response - interactive message is IHCLME.
Note: Health care claim or encounter request and response -
interactive messages conforming to this document must contain the
following data in segment UIH, composite S306:
Data element 0065 IHCLME
0052 D
0054 12A
0051 UN
00020MSD, Message action details
To specify the message processing requirements, response type, and
to provide a tracking mechanism. The reference number in this
segment will provide for a different tracking number than what is
generated in the message envelope, for application level tracking.
00030PRT, Party information
To provide specific identification numbers and demographic
information regarding the identity of the participating parties.
Date of birth, eligibility date, and date of death may be specified
as well as relationship between the patient and the insured, sex,
employment category, marital status, student status, and a yes or
no indication of whether the patient is pregnant.
00040NAA, Name and address
To specify a party identity, and, when necessary, the name and/or
the address in either a structured or unstructured format. For use
in health care, it is recommended to use only the identification,
but if the name or address are needed, to use only the structured
method of submittal.
00050CON, Contact information
To provide electronic message routing information for additional
recipients of this message. The reference number will provide a
unique reference number to be used by the contact entity when
referring to this message.
00060BLI, Billable information
To provide summarized information about all services covered under
one health care claim or encounter. This segment allows detail
relating to monetary amounts for the total amount being charged for
the claim, total amount that the patient has paid, and the total
amount paid by other benefit carriers. Multiple diagnoses that
apply to the entire claim, and multiple dates may be conveyed. The
plan sponsor can receive the reference of any pre-authorization
information associated with the claim and through a series of yes
and no indications will know whether the provider accepts the
insurance payment as payment in full, and whether the patient has
signed documents releasing the medical information to the insurance
carrier and authorizing the payment directly to the provider. The
presence, nature, date, and state or province of a cause related to
this claim, such as an accident, may also be indicated.
00070ITC, Institutional claim
To provide specific claim information only needed when processing
claims for services performed while admitted to a health care
institution. When the claim is generated from a health care
institution, additional information such as the type (e.g. first,
intermediate, last) and frequency of invoicing during an extended
admission, the number of days covered and non covered by insurance,
the type (e.g. emergency, scheduled) and source of admission, the
discharge type (e.g. ambulatory, transfer, dead), and information
about other products and services related to the institutional
admission may be needed.
00080ADI, Health care claim adjudication information
To provide adjudication information for all services, supplies or
products in the health care claim. The internal control number
assigned by the payer, the specific service trace or sequence
number designated for this service in the original claim, the
payment or draft control number, the health care service being
paid, the health case service originally billed, the health care
service institutional "revenue" code, the notification of the
adjudication action taken by the payer, the total amount paid,
other informational amounts (e.g negotiated discount), the number
of services adjudicated, the number of services originally billed,
the importance given to the diagnosis related group in calculating
the payment, the financial adjustments (e.g. deductible, agreed fee
limit) made in the adjudication, identification of health care
policy limitations, the insurance product group (e.g. indemnity,
managed care, federal program), the anticipated date of payment,
the diagnosis category from a diagnosis related grouping program,
and the percentage known as "discharge fraction" may all be sent in
this segment.
00090FRM, Follow-up action
To identify specific corrective actions that should occur before
the adjudication process can complete. The identity number in this
segment must be one of the identity number given in an ADI segment.
The follow-up actions may be for the entire claim or may be service
specific.
00100 Segment group 1: OTI-NAA
A group of segments to identify all parties by code and name that
may provide insurance coverage for the patient being treated.
00110OTI, Other insurance
To provide payer, insured and payment information when benefits
are being coordinated between third party benefit carriers. A
major source of concern in health care is being able to
coordinate benefits between multiple insurance carriers. This
segment will be used to reference other payers that may need to
be kept abreast of the health care transaction and what monetary
amounts are being paid by the respective carrier. Even though
three different carriers may be identified, there is a yes or no
indicator that will allow the indication of additional carriers
beyond what is being sent.
00120NAA, Name and address
To specify identification numbers, name and address information
relating to the other insurance parties. If available, the
identification number of the insurance carrier should be used.
When the identification number is not available, or the
insurance carrier operates out of multiple offices, the name
and/or address should be used.
00130 Segment group 2: PSI-DNT
To identify the specific service information for the claim or
encounter.
00140PSI, Service information
To provide detail information about the service, product, or
procedure. This segment allows the payer of a health care
transaction to indicate line item detail about all services
performed. All charges can be broken down, several of the
diagnosis codes from the claim can be references with an index
identifier, and any supporting evidence and out of band
additional information needed for the claim can be referenced.
00150DNT, Dental information
To provide specific a complete description of each tooth in
relation to the service. Only in a dental claim, would the payer
need to know specific tooth and additional information on the
surface, gum depth or status.
00160UIT, Interactive message trailer
A service segment ending a message, giving the total number of
segments in the message (including the UIH & UIT) and the control
reference number of the message.
4.2 Segment index (alphabetical sequence by tag)
ADI Health care claim adjudication information
BLI Billable information
CON Contact information
DNT Dental information
FRM Follow-up action
ITC Institutional claim
MSD Message action details
NAA Name and address
OTI Other insurance
PRT Party information
PSI Service information
UIH Interactive message header
UIT Interactive message trailer